Method and system for consolidating and distributing information

ABSTRACT

A method and system are provided for consolidating and distributing information. Implementation of system functionalities for both restricted local and unrestricted system-wide uses are permitted. Open standards for hardware, software and firmware components and standardized medical codes, definitions and formats are supported. The preferred embodiment of the invention provides an integrated health care system. The invention can also be used to allow secure access to Social Security, annuity, retirement account, and benefit information, allowing individuals a unified view of their benefit and payment status. A centralized host maintains, consolidates, and redistributes information generated at all networked locations. Information is electronically transferred among the system components to link an individual&#39;s local records to those stored remotely. The individual information device, centralized host computer, and any other computers or networks linked to the system can therefore be automatically updated. An individual information device stores a service recipient&#39;s insurance information, a emergency records and critical health care histories. This information is accessed by the system for use in managing any aspect of the service recipient&#39;s health care. Portable terminals can be used to access the system. A portable terminal can also be used independently from the system to perform health care functions. Unrestricted system-wide, or restricted local uses are supported. Insurance coverage for services and treatments can be determined and the information transmitted directly from the carrier(s) to the service recipient and service provider(s). Supported features include service authorization, messaging, diagnostic services, coverage determination, billing, and electronic payment.

CROSS REFERENCE TO RELATED APPLICATION

This application is a continuation of U.S. patent application Ser. No.08/960,755, filed 29 Oct. 1997.

BACKGROUND OF THE INVENTION

1. Technical Field

The invention relates to information processing. More particularly, theinvention relates to a method and system for consolidating anddistributing health care records.

2. Description of the Prior Art

Providing effective management and organization for the health caresystem is a continuing need. Many attempts have been made to improvecommunication, for example, among insurers, health care providers,health plan sponsors, and patients. However, the health care system isstill subject to significant problems in accurate record maintenance,access to information, and communication among various organizations andagencies.

Pritchard, Medical Insurance Verification and Processing System, U.S.Pat. No. 4,491,725 (1 Jan. 1985) discloses a system for verifying anddetermining a patient's background medical and insurance coverage.However, Pritchard does not integrate other essential participants inthe modern health care system. For example, a user cannot locate andschedule appointments with health care specialists, or researchtreatment options using the system disclosed in Pritchard.

Each user of an integrated health care system may maintain records andcomputer operations that are not to be distributed to the other users ofthe system. Such information as personnel records and internaldisciplinary records are typically confidential. However, it can bedesirable for the user to also be able to access these records as a partof the integrated health care system. For example, the user may wish tocompare the treatment requirements of a patient with the disciplinerecords of a health care practitioner to determine if it is appropriateto assign a case to a particular practitioner. It is therefore desirablethat the integrated health care system permit both restricted local andunrestricted system-wide uses. However, the Pritchard system does notdisclose the structure or functionalities for providing both such localand system-wide uses in the same system.

Cummings, All Care Health Management System, U.S. Pat. No. 5,301,105 (5Apr. 1994), describes a system for integrating the participants in ahealth care system. The Cummings system is designed for use by thosedirectly involved in an individual patient's health care program. Suchusers include the patient, health care provider, bank or other financialinstitution, insurance company, utilization reviewer and employer.However, the Cummings system is not designed for use by otherparticipants in the health care system, such as medical researchers, andpublic agencies. Furthermore, Cummings does not disclose support forhealth care data reporting standards. Thus, the various users of theCummings system will need to convert the non-standardized informationretrieved from the system for use in other health care reportingapplications.

Additionally, Cummings does not support auxiliary functionalities thatare often essential to providing total health care for a patient. Forexample, Cummings does not disclose support for such functionalities asSocial Security, annuity, retirement account, and other benefitinformation.

The rapid transmission of data to the appropriate sources is frequentlyof critical importance in providing health care. Portable input devices,such as personal digital assistants, are increasingly being used forcreating, maintaining, and transmitting data records. However, neitherCummings nor Pritchard discusses the use of such portable input devices.

It would therefore be an advantage to provide a method and system forintegrating the various participants in a health care system thatpermits both restricted local and unrestricted system-wide uses. Itwould be a further advantage if such method and system supportedauxiliary functionalities related to providing total health care. Itwould be yet another advantage if the method and system supported theuse of portable data input devices to rapidly create, maintain, andtransmit data records.

SUMMARY OF THE INVENTION

The invention provides a method and system for consolidating anddistributing information. Flexible configuration and access optionsprovide an array of options to best meet the needs of the serviceprovider's personal workstyle and required volume of information. Thesystem permits implementation of system functionalities for bothrestricted local and unrestricted system-wide uses. Open standards forhardware, software and firmware components and standardized medicalcodes, definitions and formats are supported.

The preferred embodiment of the invention provides an integrated healthcare system, managing all facets of modern health care, includingindividual service recipient care, public health, and health carepolicy. The invention is used to consolidate health care records, forexample for diagnostic and research purposes, and to permit immediateaccess to time critical health care information. However, alternativeembodiments of the invention can be used to capture, store, and processother types of information. For example, the invention can also be usedto allow secure access to Social Security, annuity, retirement account,and benefit information, allowing individuals a unified view of theirbenefit and payment status.

The invention provides centralized record collection and facilitates thetransfer of information among the different system components byelectronically linking an individual's local records to those storedremotely, such as on the computer systems of insurance companies, healthcare service providers, health plan sponsors, medical researchers, andservice support. A complete record of individual care is therebyprovided.

Such links between the individual service recipient's records and otherinformation systems permit the immediate transfer of results andinformation among specialist service providers and sites, libraries ofscientific literature and bibliographic information, institutionaldatabases and registries, researchers, and records of family members.Insurance coverage for services and treatments can be determined and theinformation transmitted directly from the carrier(s) to the servicerecipient and service provider(s).

In the system, an individual service recipient is provided an individualinformation device that stores the service recipient's insuranceinformation, as well as emergency records and critical health carehistories. In the preferred embodiment, this individual informationdevice is an integrated circuit (Smart) card. However, the informationdevice may include any appropriate means for storing and/or encodinginformation, such as magnetic storage cards or any other types ofportable integrated circuit or microchip-based devices.

A service provider accesses the information on the individualinformation device, for example, by swiping the card through a cardreader linked to a remote terminal or to a single or networked providerterminal. Such terminals include portable computers and personalinformation devices, or any desktop computer or networked computer.

In one embodiment of the invention, the invention is implemented using alocal area network (LAN) or intranet. In this embodiment, information istransmitted from, for example, the portable personal device, to the LANor intranet Server. This information may then be accessed by anyworkstations on the internal network and can be transmitted from the LANor intranet Server to the host computer.

In the preferred embodiment of the invention, the terminal is a portabledevice. This portable device can optionally be used to communicate withthe entire system, any portion of the system, or independently from thesystem. Restricted local and unrestricted system-wide uses can thereforebe implemented.

A centralized host processing system is used to maintain, consolidateand redistribute information generated at all access endpoints, such asfrom the individual information device, with stored information and fromany computer or other processing and storage device on the centralizednetwork. The centralized host processing system can be, for example, acomputer network, or a plurality of such linked networks having acentral server. The consolidated information is then distributed tovarious locations on the network, for example, in response to a query.

Service information, formatted service recipient records, and potentialdiagnostic codes are transmitted across the network between the remoteor provider terminal and the host computer(s). The individualinformation device, centralized host computer, and any other computersor networks linked to the system can therefore be automatically updated.

Services can be authorized through access to the central host(s), whichcan also calculate the costs of the services, as well as the amount ofavailable insurance coverage. The invention can be used to generatebilling information and to electronically transfer funds from sourcessuch as insurance carriers, bank accounts, and credit card accounts.

Each Insurance carrier can be electronically billed for the amountcharged to that carrier. The Insurance carrier can then pay the bill byelectronically transferring funds to the service provider's account at aspecified payment interval. Payment histories can be also beelectronically transferred from the Insurance carrier to the serviceprovider on the network. The charges to the service recipient can alsobe calculated and transmitted to the service recipient.

In the preferred embodiment of the invention, an on-line diagnosticservice is provided, such as a software application or an on-linediagnostician. Additionally, the system can be integrated withstatistical analysis software packages, for example, to monitor patternsin national health care, or to plot the distribution of cases of aninfectious disease.

The invention supports messaging and scheduling services, includingelectronic mail (e-mail), voice mail, and paging. Appointment recordsand administrative information can also be distributed through thesystem.

Service historical records stored on the system can be accessed byresearchers for full data analysis. The invention supports researchrequests for analysis of any of the elements of the system, such as foranalyzing legal compliance or disease management. Such historicalrecords can be stripped of identifying information before beingdistributed to researchers.

The invention promotes marketing and enrollment efforts for new andcurrent plans. Changes, for example, in plan memberships, benefits,personal information, or health care information can be automaticallytransmitted to the various participants in the system.

The invention permits participants to search records for health careproviders and organizations. Such records can include licensinginformation, staffing affiliations, organizational ownershipinformation, tax identification information, curriculum vitae oflicensed practitioners, as well as information regarding disciplinaryactions. Service recipients can access and review the contents of theirhealth care record and perform searches of research databases, forexample, regarding treatment options, and toward development of a carecontact network.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a diagram of the system for consolidating and distributinginformation, according to the invention;

FIG. 2 is a diagram of the components of the system for consolidatingand distributing information, according to the invention;

FIG. 3 is a context diagram of the system for consolidating anddistributing information, according to the preferred embodiment of theinvention;

FIG. 4 is a flow diagram of the medical insurer/benefit providerprocesses, according to the preferred embodiment of the invention;

FIG. 5 is a flow diagram of the Health/Benefit plan sponsor processes,according to the preferred embodiment of the invention;

FIG. 6 is a flow diagram of the individual service recipients processes,according to the preferred embodiment of the invention;

FIG. 7 is a flow diagram of the health care service provider processes,according to the preferred embodiment of the invention;

FIG. 8 is a flow diagram of the Medical Research processes according tothe preferred embodiment of the invention; and

FIG. 9 is a flow diagram of the service support processes, according tothe preferred embodiment of the invention.

DETAILED DESCRIPTION OF THE INVENTION

The invention provides a method and system for consolidating anddistributing information. Flexible configuration and access optionsprovide an array of options to best meet the needs of the serviceprovider's personal workstyle and required volume of information. Thesystem permits implementation of system functionalities for bothrestricted local and unrestricted system-wide uses. Open standards forhardware, software and firmware components and standardized medicalcodes, definitions and formats are supported.

The invention creates an infrastructure for health care and benefitsmanagement resulting in:

-   -   (1) support of service recipient care and improvement of        quality;    -   (2) enhancement of the productivity of health care professionals        and reduction of administrative costs associated with health        care delivery and financing;    -   (3) support of clinical and health services research;    -   (4) accommodation of future developments in health care        technology, policy, management and finance; and    -   (5) ensuring service recipient data confidentiality.

The preferred embodiment of the invention provides an integrated healthcare system, managing all facets of modern health care, includingindividual service recipient care, public health, and health carepolicy. The invention is used to consolidate health care records, forexample for diagnostic and research purposes, and to permit immediateaccess to time critical health care information. However, alternativeembodiments of the invention can be used to capture, store, and processother types of information. For example, the invention can also be usedto allow secure access to Social Security, annuity, retirement account,and benefit information, allowing individuals a unified view of theirbenefit and payment status.

The invention provides centralized record collection and facilitates thetransfer of information among the different system components byelectronically linking an individual's local records to those storedremotely, such as on the computer systems of insurance companies, healthcare service providers, health plan sponsors, medical researchers, andservice support. A complete record of individual care is therebyprovided.

Such links between the individual service recipient's records and otherinformation systems permit the immediate transfer of results andinformation among specialist service providers and sites, libraries ofscientific literature and bibliographic information, institutionaldatabases and registries, researchers, and records of family members.Insurance coverage for services and treatments can be determined and theinformation transmitted directly from the carrier(s) to the servicerecipient and service provider(s).

Services can be authorized through access to the central host(s), whichcan also calculate the costs of the services, as well as the amount ofavailable insurance coverage. The invention can be used to generatebilling information and to electronically transfer funds from sourcessuch as insurance carriers, bank accounts, and credit card accounts.

Links may also be provided to decision support systems, such asdiagnosticians, thereby increasing the treatment information availableto service providers. Additionally, the system may be integrated withstatistical analysis software packages, for example, to monitor patternsin national health care, or to plot the distribution of cases of aninfectious disease.

The invention therefore provides the data and processes necessary toimprove current and future health care services and promote diseasemanagement, while reducing administrative costs and simplifying paymentprocessing for health care providers and health care customers.

In this application, the term “function” refers to a business relatedprocedure that can be performed in one or more steps, or “processes”.These steps can be manual, automated, or both. Processes often crossdepartmental and organizational boundaries. Re-design or re-engineeringsuch processes can often improve management operation and functions,resulting in significant time and cost savings. Components are subsetsof a functional process. Additionally, in this application, “usergroups” are the users of certain system functions.

FIG. 1 is a diagram of the system for consolidating and distributinginformation, according to the invention. In the system 10, aparticipating individual is provided with an individual informationdevice 12. In the preferred embodiment, this individual informationdevice is an integrated circuit (Smart) card. However, the informationdevice may include any appropriate means for storing and/or encodinginformation, such as magnetic storage cards or any other types ofportable integrated circuit or microchip-based devices.

A centralized host processing system 14 is used to maintain, consolidateand redistribute information generated at all access endpoints, such asfrom the individual information device (not shown), with storedinformation and from any computer 16, 18 or other processing and storagedevice on the centralized network. The centralized host processingsystem can be, for example, a computer network, or a plurality of suchlinked networks having a central server. The consolidated information isthen distributed to various locations 22, 24, 26, 28 on the network, forexample, in response to a query.

FIG. 2 is a diagram of the components of the system for consolidatingand distributing information, according to a preferred embodiment of theinvention. An individual is given an individual information device 12that stores the individual's insurance information, as well as emergencyrecords and critical health care histories. This information may beencrypted.

A service provider accesses the information on the individualinformation device, for example, of a health care service recipient.When the individual information device is a smart card, the informationis accessed by swiping the card through a card reader linked to a remoteterminal 30 or a single or networked provider terminal. Such remoteterminals include portable computers and personal information devicesand provider terminals can include any computing device operating ineither a stand-alone mode or connected to other computing devicesthrough a local area network, intranet, wide area network or any otherinterconnected mode.

In the preferred embodiment of the invention, the terminal is a portabledevice. This portable device can be optionally be used to communicatewith the entire system, any portion of the system, or independently fromthe system. For example, a personal digital assistant can be used by aphysician to access a patient's medical records stored on a centralhost. The personal digital assistant can also be used on accessconfidential information stored in a database that is not connected tothe network, such as files stored in the physicians personal computer.In addition, the personal digital assistant can be used independentlyfrom the system, such as to maintain work and appointment schedules, orto store personal notes.

Service recipient information is transmitted from the remote terminal orprovider terminal across the network to the host computer(s) 14.Information such as detailed histories and records stored on the hostcomputer are accessed and downloaded to the service provider's computingdevice 32 or to a high volume configuration such as a localized serveror host 36. The individual information device may then be updated by newinformation in the information downloaded from the host computer 14.

Formatted service recipient record and potential diagnostic codes may bedownloaded from a network server, or the host computer to a portablepersonal device or terminal for use by a health care practitioner, forexample, during an appointment with the service recipient. Informationgathered by the practitioner may also be uploaded to the server, hostcomputer, or individual information device. Thus, for example, theservice recipient will be provided with an updated electronic record ofnew procedures and medications prescribed by the health carepractitioner and the service recipient information on the central hostcomputer will also be updated to reflect the changes.

Appointment records and administrative information may also bedistributed through the system. Thus, a health care practitioner mayview the day's scheduled appointments, receive health care records foreach service recipient, record relevant information from eachappointment, and receive memos from, for example, an Insurance carrieror a hospital using the portable personal device or provider terminal.

In one embodiment of the invention, the invention is implemented using alocal area network (LAN) or intranet 42. In this embodiment, informationis transmitted from, for example, the portable personal device 12, to acomputer 34 that is connected to the LAN or intranet server 36. Thisinformation may then be accessed by any workstations or other computers41 on the internal network and can be transmitted from the LAN orintranet server to the host computer 14.

In the preferred embodiment of the invention, an on-line diagnosticservice is provided. In one embodiment, this service is a softwareapplication. This application allows a service provider or servicerecipient to identify symptoms and search for potential diagnoses,procedures, medications or pharmaceuticals, support groups, specialistsand other care options, pertinent research, on-line video, audio andother multimedia options. The software application also providescommunication access features to individuals and organizations.

In an alternative embodiment, the diagnostic service is an on-linediagnostician. For example, the practitioner can submit information andquestions through the network to an on-call physician. The physician canthen respond immediately with a diagnosis, treatment recommendations, ora request for further information. Alternatively, the information can bestored in a dedicated database for later diagnosis by a diagnostician,or in a general database for review and suggestions from anypractitioner who uses the invention.

Following treatment, the service provider transmits diagnostic andprocedure codes to the system. Insurance coverage for the servicesprovided is then calculated. This calculation may be performed at anyappropriate device on the network, including a remote terminal, portablepersonal device, service provider's computer, network server, or hostcomputer. If the service recipient has multiple insurance carriers, orif insurance deductibles apply to the services provided, the serviceprovider's records are updated with the appropriate billing parties andamount chargeable to each.

Each insurance carrier can be electronically billed for the amountcharged to that carrier. The insurance carrier can then pay the bill byelectronically transferring funds to the service provider's account at aspecified payment interval. Payment histories can be also beelectronically transferred from the Insurance carrier to the serviceprovider.

The charges to the service recipient can also be calculated by thesystem and transmitted to the service recipient through the remoteterminal, provider terminal, or portable personal device. Thus, theservice recipient can be advised of the total charges, amount ofinsurance charges, and the amount for which the service recipient isliable prior to authorizing any treatment.

In the preferred embodiment of the invention, administrative informationtransfers are transmitted to the centralized host system during non-peaktimes. Thus, invoices, appointment lists, messages, and payment recordsmay be transmitted, for example, at night. Batch transfers arepreferably used in appropriate instances for high-volume, non-criticalinformation transfers to reduce bandwidth overhead and networkcontention. However, on-line access approaching twenty-four hour, sevendays per week is available for service recipient record access andupdates. Emergency and critical information transfers are therebysupported.

The invention facilitates information retrieval and analysis forresearch. Service recipient historical records stored on the system canbe accessed by researchers for full data analysis. Such historicalrecords can be stripped of identifying information before beingdistributed to researchers.

Research requests can be sent to the system, and run, for example,during non-peak processing times to minimize system resource contention.Data can then be returned to the requesting party through the party'scommunication link. The invention supports research requests foranalysis of any of the elements of the system, such as for analyzinglegal compliance or disease management.

In the preferred embodiment, data can be stored in a relationaldatabase. Keys such as subscriber identification number, insureridentification number, prognosis, and treatment codes can be used toindex this relational database. In the preferred embodiment, the servicerecipient record data is chronologically indexed to create a continuoushistory of the service recipient's health care.

The contents of a service recipient's record can include, for example:

-   -   (1) uniform core data elements;    -   (2) standardized coding systems and formats;    -   (3) common data dictionary; and    -   (4) information on outcomes of care and functional status.

The core data elements are a set of information fields defined inaccordance with federal and international standard settingorganizations. These include standard codes for diagnoses, procedures,medications and other elements of health care, standard identifierinformation for service providers and insurers, and standard dataformats for maintaining and transmitting record information. All dataelements and their coded values and textual descriptions are maintainedin a common data dictionary, which is one of a shared set of platformservices used by all system components during processing. (See, forexample, FIG. 9).

Records for each service recipient served by the system are stored in aSubscriber/Medical history database. All personal and health carerecords are included in this centralized database. These records includestandard codes for all plans/benefits for which the service recipient isa participant. These codes are used to link to a Plan/Benefit databaseto access detailed records of a service recipient's coverage.

The service provider standard codes, defined under the Plan/Benefitdatabase record, are used to link to detailed information maintained ina service provider database. In this way, standardized codes are used toaccess records throughout the system. These records can therefore bemaintained at a single location, improving access and eliminatingerror-prone multiple entries.

Service records within the service recipient's Subscriber/medicalhistory record are preferably stored in chronological order. Theserecords can contain multiple fields relating to the episode, care,outcome of care, and functional status. The personal information deviceof the service recipient can hold either a selected subset of the fullservice recipient record or the full record. In the preferred embodimentof the invention, the available storage parameters are used by thesystem to define a critical subset of the service recipient record to bestored on the card.

In the preferred embodiment of the invention, a standardized,patient-oriented health care record with display of service recipientidentification and emergency information followed by sequential episodesof care is used as a default format for service provider and servicerecipient access. This default format can be displayed as a screendisplay or graphical user interface (GUI). A customized screen displaycan also be provided to meet the specific needs of a system user. ThisGUI can present the standardized health care record for the servicerecipient as it is downloaded from the individual information device orfrom the total record stored in the Subscriber/Medical history database.This standardized health care record can include:

-   -   (1) A structured, systematically collected database of service        recipient health care records constructed at the point of        service and collected during the service process;    -   (2) An easily reviewed and updated problem list using standard        diagnostic codes. Definitions can be updated and new diagnostic,        procedural and medication codes created and stored in the        central records;    -   (3) Records of clinical formulations and plans for care and        follow-up can be stored in the central host databases for use,        for example, by all research organizations and agencies in        assessing care components.

In addition, intelligence built into the system includes decisionsupport, clinician reminders, and customizable “alarm” systems asexplained below, in detail, in Al Medications/procedures. Multiplestandard reporting formats, such as hard copy reports, and billing andpayment reports, are also available to all clients on a daily, weekly,monthly and annual basis.

In the preferred embodiment of the invention, all central host databasesuse a standardized common data dictionary to ensure standardization ofall system database elements. The common data dictionary can store fielddefinitions, acceptable codes or values, edit rules, format rules, dataowner showing who has ultimate authority to issue updates and revisionsto the field. The data dictionary fields can also contain references toother diagnostic, procedural, pharmaceutical and personal informationcodes to identify potential incompatibilities or problems.

This data dictionary can be used in the processing of changes to thedatabases and in the construction of research requests. In addition, adatabase, such as the Medications/Procedures database can access thedata dictionary codes when responding to a query. The data dictionarycan then be used to limit the information retrieved in response to thequery to those cases containing no potential incompatibilities orproblems. In this way, the information stored in the data dictionary canbe used to enable other functional capabilities of the system.

The lists of standardized codes for all prognoses, medications andtreatments are centrally controlled. Full cross element edits areincluded to flag potentially invalid or incorrect entries. The values inthe data dictionary can be used to construct a customized edit of aservice recipient record. The use of such common data dictionary,standardized coding schemes, and uniform data sets promotes complete,reliable analyses of care and disease patterns.

This invention employs the use of open standards promulgated bystandards organizations. Such open standards include the open standardsdefined for hardware, software and firmware components. For example, useof the open standard for integrated circuit cards can significantlyreduce the cost of card production, and increase the availability ofcompatible components, such as card readers. Additionally, use of theopen standard can enable the card to carry other value-added consumerinformation regarding additional services, products, organizations andcorporation.

Customized GUI formats implementing such standard elements can beconfigured to follow the standards of different specialties, forexample, as defined by the American Medical Association or otherspecialist and international organizations. Technology support standardsfrom unified representation, such as those developed by the NationalInstitute of Standards and Technology and the International StandardsOrganization's (ISO) Open Systems Interconnect (OSI) model can also beimplemented.

A standardized vocabulary developed from unified representation, such asthe Systematized Nomenclature of Medicine, the Read ClinicalClassification in Great Britain, the ASTM Standard Guide for NosologicStandards and Guides for Construction of New Biomedical Nomenclature andthe National Library of Medicine's UMLS project, can be used with theinvention. The preferred embodiment of the invention also supports theuse of standardized formats for health care data interchange fromunified representation, such as HL7 (Health Layer 7), an AmericanNational Standards Institute (ANSI) accredited standards organization,ANSI X12 electronic data interchange formats for health care informationcommunication (published by the Data Interchange Standards Association,also known as DISA), National Provider Identifier and PAYERID(initiatives of the US Health Care Financing Administration foridentification standardization for service providers and health carepayers, respectively), Institute of Electrical and Electronics Engineers(IEEE), Medix, standards for transfer of clinical data from the AmericanSociety for Testing and Materials, and the American College ofRadiologists/National Electrical Manufacturers Association standards forimage transfer.

The system software is designed as a distributed model with softwaremodules stored at either their point of use or point of access. Thecentral host(s) preferably maintains the central databases, datadictionaries, centralized communication functions for informationalupdating, routing and messaging, centralized servicing includingdatabase maintenance, remote systems management, customer servicing,funds transfer processing, data warehouse querying, statistical analysisprocessing, exception processing, record and processing overrides, andservice billing and accounting applications.

For service providers, a server can store subsets of the centraldatabases, applications for performing batched update functions, andsoftware modules for accessing functionalities of other systemcomponents. This model allows localized sharing of data among serviceproviders operating within a single administrative setting, for example,within a hospital or clinic, without the delays and additional costs ofcontinual central host accesses. Restricted local and unrestrictedsystem-wide uses can therefore be implemented.

In a single terminal embodiment of the invention, the terminal (forexample, the provider terminal, or a personal digital assistant) canstore subsets of the central databases, applications for performingbatched update functions, and software modules for accessingfunctionalities of other system components. In addition, the terminalstores the applications required to access and transfer information toand from the individual information device.

For the other functional users of the system, the applications forperforming the various users' processes can reside on the users' localcomputers or localized server configuration. Alternatively, any subsetof the software applications, such as communications and securitysoftware only, can be stored on the user's computer, while additionalapplications are accessed from the central host/server. In all cases,records for all databases are accessed and stored at the central host.

The invention provides security for restricting access to the system toan authorized user. The types of security supported by the inventioninclude password protection, encryption, and identificationauthentication. This security is provided by a security module withinthe user's computer or individual information device and used inconjunction with passwords. Information regarding such securityattributes and procedures can be stored in a security management sharedplatform service for use by all system processes and components.

The invention can be used in conjunction with data storage, backup, andrestore mechanisms to safeguard records in the event of system failures.These system management features are included within theApplications/Management shared platform services and are used by allcentral host databases. Personal or networked computers used by varioussystem users can be customized to provide remote or local data backup,archive and restore capabilities. Additionally, data can be fullyrestored from the files of the central host(s).

FIG. 3 is a context diagram of the system for consolidating anddistributing information, according to the preferred embodiment of theinvention. This diagram shows the primary functional areas of the systemand identifies the users of each functional area. The system 50 linkstogether functional areas such as Medical Insurers/Benefits Providers52, Health/Benefit plan sponsors 54, individual service recipients 56,health care service providers 58, Medical Research 60 and servicesupport 62.

Medical Insurers/Benefit Providers 52 include:

-   -   (1) benefit managers;    -   (2) federal, state and private insurers;    -   (3) business health care coalitions;    -   (4) employers who self-insure or manage their own benefits        packages; and    -   (5) annuity and retirement account management organizations.

Processes supported by the invention include plan definitions. In suchplan definitions, an insurer defines a new plan or changes an existingplan, including coverage options, geographic coverage, lifetimetreatment limits, support features, procedures and medications covered,service providers and/or categories of services provided, limitations ongroups or individuals applying for coverage, automated authorization ofbenefits, service recipient automated referrals, service paymentaccounting with payment service network integration, providingcommunication in the event exception processing is required, andreporting and statistical analysis. Changes in plan definitions can beautomatically communicated to current service providers and plansponsors. Plan definitions can also include open enrollment marketingfeatures. Such open enrollment marketing features can include featuressupporting simplified design of an on-line plan summary for accessingthe plan definition information within the central host database and forresponding to plan sponsor requests for contact, and update methods foradding, deleting and changing service recipient plan participationrecords.

All health care program providers are identified within, andelectronically linked to, the system and are therefore provided withup-to-date information. Thus, problems associated with service providerstatus are avoided. For example, the service recipient or referringservice provider is informed when a provider ends its affiliation with acare plan and can therefore select another, affiliated provider.

The invention also can reduce the costs of publishing and distributingdirectories of caregiver information. New medical insurer/benefitprovider defined plans are communicated to providers and to plancustomers automatically by the central host as the plans areimplemented, changed or discontinued. Thus, all customers and suppliersof an affected plan are aware of changes in plan coverage.

Health/Benefit plan sponsors 54 include:

-   -   (1) health and benefit plan management staff; and    -   (2) human resource department staff.

The processes supported by the invention include support of openenrollment, in which the medical insurer/benefit provider creates arecord within the Plan/Benefit database specifying plan parameters(detailed information on plan coverage) which are accessible to plansponsors, service recipients and service providers through features ofthe full system. These processes allow plan sponsors to search for newapplicable plans, and allow service providers to investigate new servicerelationships.

Changes to existing plans, are automatically communicated to plansponsors and service providers with current plan relationships, by thecentral host. When changes are made to existing plans, the MedicalInsurer/Benefit Provider can request, during the queuing of the updatefile to the central host, that current service providers and plansponsors be notified by an electronic message of the changes to theplan. This is described below, in detail.

Individual service recipients 56 include health care and benefitconsumers such as:

-   -   (1) service recipients; and    -   (2) service recipient family members.

Processes supported by the invention include updating records andmessaging. Such messaging services can include electronic mail (e-mail),voice mail, and paging. Service recipients can review the contents oftheir health care record and its associated payment history, identifyerrors and omissions therein, and include treatment plan preferences.

The invention permits service recipients to search the ArtificialIntelligence (AI) Medications/Procedures database regarding treatmentoptions and medications and procedures information, and search theSubscriber/medical history database toward development of a care contactnetwork. The invention also supports health plan enrollment and use byproviding features allowing service recipients to review plan coverageparameters and service provider networks affiliated with health plansoffered by their plan sponsor. Communication to all members of a servicerecipient's health care network are supported by the system.

Medical service providers 58 include:

-   -   (1) alliances, associations, networks and systems of providers;    -   (2) ambulance services;    -   (3) ambulatory surgery centers;    -   (4) donor banks including those for blood, tissue and organs;    -   (5) health maintenance organizations;    -   (6) home care agencies;    -   (7) hospices;    -   (8) hospitals;    -   (9) nursing homes;    -   (10) preferred provider organizations;    -   (11) physician offices;    -   (12) psychiatric facilities;    -   (13) public health departments;    -   (14) substance abuse programs;    -   (15) dental service providers;    -   (16) pharmacies;    -   (17) testing facilities; and    -   (18) therapeutic care providers.

Functions supported by the invention include accessing service recipienthistories and updating service recipient records. Services can beauthorized through access to the central host(s). The central host canalso calculate, and attach to all pertinent records, the amount ofpayment required from each of multiple parties, health care historyupdates (including payment calculations and authorization of services,automated referrals with communication linkages, etc.), AImedications/procedures available for diagnostic and treatment support,and research requests. In addition, the system manages and servicespayments and record keeping, including automated invoicing forun-reimbursed service recipient accounts.

Medical Research 60 include:

-   -   (1) allied health professional schools and programs;    -   (2) medical schools;    -   (3) nursing schools;    -   (4) public health schools;    -   (5) accreditation organizations;    -   (6) institutional licensure agencies;    -   (7) professional licensure agencies;    -   (8) disease registries;    -   (9) federal, state and local government policy-makers;    -   (10) agencies investigating legal compliance;    -   (11) lawyers;    -   (12) health care researchers and clinical investigators;    -   (13) health care technology developers and manufacturers;    -   (14) health data organizations;    -   (15) health sciences journalists editors;    -   (16) research centers;    -   (17) medicare peer review organizations;    -   (18) quality assurance companies;    -   (19) risk management companies;    -   (20) utilization review and management companies; and    -   (21) service providers and service recipients.

The needs of the users of this functional area are supported by links toinformational databases, statistical reporting applications, andsoftware features for collecting data and constructing customizeddatabases. The use of standardized codes permits the users to readilyretrieve information necessary for the long-term analysis of treatmentmethods and outcome of care.

Service support 62 includes the agencies and staff for updating andmaintaining the system, including:

-   -   (1) service parameter maintenance;    -   (2) product support;    -   (3) customer requests; and    -   (4) system maintenance.

The processes supported by this functional area of the invention includethose for performing system maintenance, security, customer service andbilling functions and for international, federal or state authorizedagencies to automatically update centralized information. Designatedagencies such as the Agency for Health Care Policy and Research andauthorized organizations such as state licensing review boards can beprovided with secure access to the system for updating and maintainingrecords. Additionally, the system is continually updated to includecurrent health care standards, as well as information regarding allusers of the invention.

Licensing and other regulatory information is preferably stored in aservice provider record within the service provider database. Thisinformation is available to all authorized users of the system and canbe updated or used for research requests by regulatory agencies.Security levels are defined within the Security management component ofthe shared platform of services.

As an example, records for service provider organizations within theservice provider database can contain licensing information, staffingaffiliations, organizational ownership information and taxidentification information required to monitor legal compliance. Theservice provider records can include the curriculum vitae of a licensedpractitioner, as well as information regarding any disciplinary actionsagainst a licensed practitioner or service provider.

The medical insurer/benefit provider (see FIG. 3, element 52) functionalarea supports all aspects of service recipient care reimbursement. FIG.4 is a flow diagram of the medical insurer/benefit provider processes,according to the preferred embodiment of the invention. Plan Definitionprocesses 100 are available to update medical/benefit plans stored inthe Plan/Benefit database 102, located at the central host(s).

The medical insurer/benefit provider accesses the central host(s), andprovides required security responses to download current insurer recordsfor the specified plan(s) from the Plan/Benefit and service provider 104databases. Software applications, preferably operable on the medicalinsurer/benefit provider's computer, is used to add, update or deleterecords to/from the databases. Such updates include the review,deletion, and revision of existing plans, as well as the creation of newplans through the setting of new plan parameters. Plan parametersinclude the identification of procedures, pharmaceuticals, serviceproviders and other care plan components covered by the medical/benefitplan, and the determination of payment and reimbursement ceilings andout-of-network service coverages.

The date on which a change is to occur can be included in the records.Batched update features and copy capabilities for current recordinformation is available to simplify changes to records. The medicalinsurer/benefit provider computer can access the central host(s) anddownload an updated file, with any other information regardingimplementation dates/times, automated notifications of changes, andwhether service recipient records are to be updated with plan changes.

Open enrollment processes 106 are available to support marketing andenrollment efforts for new and current plans by supplying on-lineinformation for access by, and/or automated distribution to,Health/Benefit plan sponsors and their respective service recipients.The medical insurer/benefit provider accesses the central host(s), todownload current medical insurer/benefit provider records for thespecified plan(s) from the Plan/Benefit and service provider databases.

The medical insurer/benefit provider then can construct or change theplan marketing information. When all changes have been completed, editedand audited, the updated file is downloaded to the central host(s).

Health/Benefit plan information is available to potential customers, forexample, through non-solicited searches by other service providers, plansponsors, and service recipients for other available plans. PotentialHealth/Benefit plan sponsors or service recipients can review theinformation and communicate with the medical insurer/benefit provider'smarketing and sales staff. Potential service providers can also applyfor inclusion in a plan by communicating with the medicalinsurer/benefit provider.

When a plan sponsor elects to participate in a new plan, to change planrecord information, or to drop participation in a plan, the medicalinsurer/benefit provider updates the Plan/Benefit database with plansponsor information. In addition, the medical insurer/benefit providercan update the subscriber/medical history database when newsubscribers/service recipients are enrolled or changes are needed to asubscriber/service recipient's record.

The medical insurer/benefit provider accesses the current Plan/Benefitrecords from the Plan/Benefit database stored on the central host(s),and/or subscriber/medical history records from the subscriber/medicalhistory database for the specified plan sponsor group(s). These recordscan then be reviewed, modified, or deleted, as desired.

In the preferred embodiment of this invention, a field indicator on thesubscriber/service recipient record can be used to request a new orreplacement individual information device.

Automated authorization of benefits 108 is also provided by theinvention. When authorizations for services are submitted by a serviceprovider during the Update Medical History process, a record containingservice recipient identification and plan information, service provideridentification, and procedure and/or medication codes is transmitted tothe central host(s). The central host tags the request with a uniqueauthorization request number, verifies the service recipient planinformation from the subscriber/medical history database, and verifiesstatus of the service provider.

The request is then compared to plan coverage information parameters forthe affected plan(s) from the Plan/Benefit database. If multiple payersare involved, payment amounts are calculated for all affected parties.An authorization record is created in the provider servicehistory/Payment database and in the subscriber/medical history database.

The applicable approval codes and payment amounts are added to theservice provider authorization record. The authorization record cancontain standard formats and codes of international standard settingorganizations, such as 837 Health Care claim Process in X12 from theData Interchange Standards Organization. When a request forauthorization is declined, due to parameters of the plan, the centralhost(s) transmits an on-line decline message to the medicalinsurer/benefit provider and the service provider. A manual reviewprocedure for handling exceptions, appeals and questions can then beinitiated.

Patient automated referrals 110 identifies specialist service providers,hospitals, and clinics participating in a Health/Benefit plan, asdefined in the service provider database 104. If, during the UpdateMedical History process, the service provider wishes to refer a servicerecipient to a specialist service provider, hospital, clinic or otherreferral organization, a referral request is transmitted, along withservice recipient plan information, from the service provider computerto the central host(s).

The central host(s) uses these codes to construct a search of theservice provider database. Search results are returned to the requestingservice provider for display in a selectable GUI on the service providercomputer. The service provider can then select the record for thedesired referral provider.

The service provider database search can be limited to in-planproviders. Alternatively, the service provider can perform a geographicor affiliation search, or can identify a specific targeted referralprovider. The service provider can then perform a service authorization,as defined above.

Authorization approval is returned from the central host to the serviceprovider computer. A message requesting an appointment for the servicerecipient, including the phone number to call for scheduling can beautomatically constructed and transmitted to the referral serviceprovider.

The preferred embodiment of the invention provides accounting services112 to users. Such accounting services include the transmittal ofinvoices from a provider service history/payment database 114 to themedical insurer/benefit provider. Payments of these invoices may be madeelectronically, with funds transferred directly from the medicalinsurer/benefit provider's account to that of the service provider.

The medical insurer/benefit provider can identify specific accounts fromwhich a payment is to be made, and can record the date of the paymentand information regarding its transfer. A payment history can also begenerated and stored in the provider service history/Payment database114. Such payment history can then be appended to the servicerecipient's medical history.

The medical insurer/benefit provider accesses the central host(s) toretrieve unpaid provider service history records for the specifiedplan(s) from the provider service history database. If desired, currentplan and provider information can be retrieved from the Plan/benefit andservice provider databases.

Software applications operable on the medical insurer/benefit provider'scomputer are used to approve records for payment. Account informationfrom the service provider database can be used to define the electronicfunds transfer parameters. Records can be batched into folders foroperational handling purposes, and electronic and printed audit reportscan be generated. The payment record can contain standard formats andcodes of international standard setting organizations (such as 837Health Care claim Process in X12 from the Data Interchange StandardsOrganization).

If exception items are identified, an exception handling message can beconstructed and prepared for routing, using the parameters of theservice provider record, including communication addresses. An updatedfile is transmitted to the appropriate database(s) on the centralhost(s).

The invention supports reporting and statistical analysis processes 116for information stored in the subscriber/medical history, plan/benefit,service provider, and provider service history/payment databases 114.Such processes include providing reporting and statistical informationfor service provider monitoring, and providing service data for benefitcalculations.

Organizational summaries can be generated for use in developing practiceguidelines. Practice guidelines are systematically developed statementsfor assisting practitioner and patient decisions regarding appropriatehealth care for specific clinical conditions. Organizational summariescan also be generated for use in outcomes management. Outcomesmanagement is the assessment of ultimate results of efforts to prevent,diagnose, and treat various health problems.

A statistical analysis of the cost and outcomes of care information canreadily be performed to assist a service provider in budgetingdecisions. Full service recipient care information can also beelectronically provided for use in adjudicating of claims and makingcoverage decisions. The medical insurer/benefit provider accesses theResearch Request database 162 on the central host(s) to download datadictionary information for the central host databases, including thesubscriber/medical history 122, Plan/Benefit 102, service provider 104and provider service history 114 databases. This information can bestored on the medical insurer/benefit provider's computer, as desired.

The medical insurer/benefit provider can then use software operable onthe provider's computer to construct a data query. Desired data fieldsare selected from the data dictionary of the central databases, ensuringfrom the rules in the data dictionary that appropriate authority isavailable for access to the data. Security rules limit access to certainfields, and requests for non-authorized data are returned from centralhost processing with a security restriction message.

Data queries can be specified as one-time only or can be requested on anongoing, time-specific basis for continuing research efforts. When alldata queries have been completed, the request file is transmitted to thecentral host(s) and the data search is performed. The search results, oran error message, is then returned to the medical insurer/benefitprovider.

The Health/Benefit plan sponsor (see FIG. 3, element 54) functional areaof the invention supports Health/Benefit plan management staff and humanresource department staff. FIG. 5 is a flow diagram of theHealth/Benefit plan sponsor processes, according to the preferredembodiment of the invention.

Open Enrollment processes 120 are available to support changes tocurrently sponsored benefit plans and to support requests for theproduction and distribution of individual information devices. Thesechanges are implemented through access to the central host, as describedabove.

Modifications can be made, for example, to change benefit information,such as additions, changes or deletions to auxiliary reimbursementaccounts, insurance, annuity, retirement or workman's compensationplans, in the Plan/Benefit database. These changes can be made manuallyor electronically. Modifications can also be made to plan participationrecords in the subscriber/medical history database.

Production and distribution of new or replacement individual informationdevices can be requested by the medical insurer/benefit provider. Inthis way, requests for new devices, for replacement of existing devices,and for deactivation of devices are transmitted electronically throughthe central host(s) from the Health/Benefit plan sponsor to theauthorizing medical insurer/benefit provider.

When all changes have been completed, the updated files are transmittedto the central host(s). The central host can then distribute theseupdated files to the various components of the system.

Research plans processes 124 are available to permit plan sponsors tosearch for available applicable plans within the Plan/Benefit database.Plan sponsors are also able to review and compare available plans and tocommunicate with a medical insurer/benefit provider to apply forinclusion in a new plan. In addition, when medical insurer/benefitproviders add or update plans, electronic notification is automaticallysent automatically to affected parties.

The electronic communication features support exception item processingand dispute resolution among medical insurers/plan sponsors, serviceproviders and service recipients. This is accomplished by allowing theplan sponsor to copy records involved in the exception or dispute fromthe subscriber/medical history database, Plan/Benefit database and/orservice provider database into a message for involved parties. Thismessage can include text supplied by the plan sponsor.

The plan sponsor accesses the central host(s) to retrieve electronicmessages or download previously requested files, review available planson-line, send electronic messages constructed on-line or off-line,and/or submit a request for access to applicable records from thecentral host databases. This information can be stored on the plansponsor's computer for later use.

The plan sponsor can then construct a search for applicable new plans byloading subscriber/medical history records into a summary criteria dataquery format GUI. This information is transmitted to the central host(s)to, for example, create a search for other applicable plans, review planinformation, request marketing information, or respond to plan andcoverage issues.

Benefit usage management processes 126 allow the Health/Benefit plansponsor to access information stored in the subscriber/medical history122 and Provider/Service History 114 databases. This information canthen be used for management of medical care reimbursement accounts,workman's compensation or other auxiliary plans. The Health/Benefit plansponsor can also use this information to respond to queries on serviceparticipant benefit selection and usage, service audits and informationfor tax and reporting purposes.

The plan sponsor accesses the central host research request database todownload data dictionary information for central host databases,including subscriber/medical history 122, Plan/Benefit 102, serviceprovider 104 and provider service history 114. This information can bestored on the plan sponsor's computer for later use, for example inconstructing data queries. Data queries can be specified as one-timeonly or can be requested on an ongoing, time-specific basis forcontinuing efforts, such as electronic transmission of data toreimbursement plans on a regular basis. The individual servicerecipients (see FIG. 3, element 56) functional area of the inventionsupports service recipients, their families and dependents. FIG. 6 is aflow diagram of the individual service recipients processes, accordingto the preferred embodiment of the invention.

A service recipient is provided with an individual information devicewhich holds identification and critical care information. In thepreferred embodiment of the invention, this individual informationdevice is an integrated circuit card, also known as a Smart Card.

The individual information device stores a summarized health carehistory of the service recipient. This summarized history is availableto service providers in the event of a health care emergency and can bereadily updated through the electronic network. The summarized healthcare history can include information regarding chronic healthconditions, allergies to medications, medications currently prescribed,and emergency family contacts.

For example, a paramedic providing emergency health care treatment tothe service recipient can use the individual information device toreview the service recipient's diagnostic and treatment history,emergency contact information, allergy and other critical informationand plan coverage records through the use of a portable reader device.In addition, a paramedic having access to the central host can use thehost's diagnostic features, in conjunction with the service recipientrecord, to aid diagnosis of a problem and isolate a possible course ofemergency treatment.

The electronic health and personal record eliminates the need for aservice recipient to fill out paper forms at a service provider officeor to try to remember episodes of care and the affiliated dates. Also,the automated service and authorization features of the central host(s)eliminates the problems of selecting referral service providers coveredby the service recipient's plan(s), and identifying paymentresponsibility for treatment.

Further features allow service recipient's access to health caretreatment option information (through access to the AIMedications/Procedures 144 features) and allow service recipients tocreate a care network by communicating with others who currently or havepreviously suffered from similar health care diagnoses.

Updates and messaging processes 130 allow the service recipient tocommunicate with health care providers such as practitioners, insurers,and sponsors. The service recipient can access the central host toelectronically research care options provided under the servicerecipient's Health/Benefit plan and access expert health care databases.

Electronic messages can be retrieved, previously requested filesdownloaded, available plans reviewed on-line, and electronic messagessent. Requests can be made for access to applicable records from thecentral host databases. Plan/Benefit information can include informationabout other types of benefit plans, including reimbursement accounts,insurance, annuity, retirement or workman's compensation plans.

The service recipient can use this information to review planinformation, treatment and payment histories, construct messages to aplan sponsor for replacement of an individual information device, or askquestions regarding plan options or usage. The service recipient canalso initiate changes in the recipient's medical history record. Suchchanges can include emergency, allergy, contact, identification ortreatment preference option information, notations on functional healthstatus or errors found in the health care history record during anaudit. Messages can be sent to service providers regarding questions,treatment options, or requests for appointments. Messages can be sent tomedical insurer/plan sponsors regarding questions, coverage issues,payment records, dispute resolution, regarding research queries ondiagnostic options or for contact information. For all processescompleted while operating in an off-line mode on the service recipient'scomputer, the service recipient repeats the process described above toconnect to the central host(s) and collect and transmit new messages.

Health plan enrollment and use 132 processes provide access to healthplan information during open enrollment periods. The service recipientcan periodically access the Plan/Benefit database 102 to review changesto plan parameters such as approved procedures, pharmaceuticals,providers, payment/reimbursement ceilings, and out-of-network servicescoverage parameters.

For example, information on multiple plans for health plan enrollmentevaluation can be loaded into a comparison form at the servicerecipient's computer to provide a feature by feature comparativeanalysis of available plans and their respective treatment options,coverage limits, service providers, etc. This information can be used toconstruct messages and requests to medical insurer/benefit providers,service providers or plan sponsors for further information,clarification or action. For all processes completed while operating inan off-line mode on the service recipient's computer, the servicerecipient repeats the process described above to connect to the centralhost(s) and collect and transmit new messages.

In the preferred embodiment of the invention, medical/benefit planhistory records processes 134 are available to access informationpertaining to their care or the care of their family members which arestored in the central host databases including the subscriber/medicalhistory 122, Plan/Benefit 102, service provider 104 and provider servicehistory/Payment 114 databases. The service recipient can thereforereview allergies and emergency information, health plan status,identification, and emergency contact information, health care historyrecords and service history/payment records.

Information from the subscriber/medical history record can be formattedinto a health care history and subscriber information record. Theservice recipient can “flip through” these records, allowing an audit ofcurrent services, diagnoses, procedures and medications, and paymenthistories. Messaging features are also supported.

Using a service recipient features GUI, the service recipient selects amessage option, and identifies a selected plan sponsor (if there aremore than one). The system then constructs a message form which theservice recipient can use, for example, to request replacement of anindividual information device, change personal records, or ask questionsregarding plan options or usage. This message can be transmitted throughthe central host(s) during the service recipient's next on-line session.

Changes to the service recipient's health care history record areimplemented by selecting an information history change or additionoption to note changes, for example, to emergency, allergy, contact,identification or treatment preference option information, notations onfunctional health status (such as current condition updates for healthmonitoring like results of home testing on a regular basis) or tocorrect errors found in the health care history record during an audit.These changes will be routed to central host(s) database administrationduring the next on-line session.

A construct message option permits the service provider to communicate,for example, questions, requests for appointments, queries regardingfunctional health status and results of administration of home tests.Information relating to the request and additional notes and commentscan be append to a communication. A construct search option permitssearches of system records.

An additional formatting option allows the service recipient to usehealth care information and payment records to construct printedreports, including IRS accountings of health care services and costsduring a given tax year, listings for health care reimbursement plans,or general health care information records.

Artificial Intelligence (AI) Medications/Procedures 144 processes allowthe service recipient to review results of consumer queries regardingprocedures, medications, and other care components from a constructedsearch of the AI Medications/Procedures Database. This databasemaintains information on current treatments and medications, includingcompany names and cost information. The database may also includedescriptions of diseases and information regarding their causes, as wellas preventative advice or health maintenance information.

Supported AI medications/procedures processes include databasesearching, and messaging. In the preferred embodiment of this invention,these service recipient features are off-line processes, therebyreducing contention on the central host databases. However, an alternateembodiment of the invention supports direct connection and on-linesearches by the service recipient of the Medications And Proceduresdatabase 146, as well as access to records in the other central hostdatabases.

Health care service provider processes support private health carepractitioners, service recipient care providers, health care deliveryorganizations, hospitals, and emergency health care services. FIG. 7 isa flow diagram of the medical service provider processes, according tothe preferred embodiment of the invention.

Service recipient history processes 140 support the review of healthcare history records stored on the service recipient integrated circuitcard and, for a full and detailed record, on the subscriber/medicalhistory database 122. Portable devices, such as mobile units can be usedto access emergency information stored on the service recipientindividual information device. Such access can be made either on oroff-line.

The service provider swipes the individual information device through anattached card reader. If the service provider is operating in an on-linemode, the service provider accesses the central host(s), providesrequired security responses, and transmits identification parametersfrom the ICC record, which identifies the full record on the centralhost(s) subscriber/medical history database and downloads the fullrecord.

If the service provider specifies a request to download diagnosticcodes, software operable on the service provider's computer allows theservice provider to identify categories for selection of appropriatedetailed diagnostic codes for use during the consultation. These codes,along with the service recipient record, can be transmitted to ahand-held or digital personal assistant device if desired, or can beprinted for use during the examination. Full diagnostic code sets canalso be resident on the service provider's server, downloaded with otherbatched transfers, if a larger volume computing configuration is beingused by the service provider.

Once available, the full service recipient record is loaded intosoftware operable on the service provider computer, which formats therecord into a desired screen format, which can also be printed. Thisformat can be of a standard problem-oriented medical record,time-oriented medical record or any other customized format, as selectedby the service provider. Diagnostic, procedural and medication codes areshown with their definitions, as available through the central host(s).These codes can be downloaded at any time and stored for furtheroff-line usage.

In addition, all codes for medical plans/benefits can be shown with fulltextual code descriptions in the language specified by the serviceprovider. Service recipient information contains a detailed health carehistory including procedures and medications and dates of both,emergency, allergy, contact and identification information, insuranceinformation, functional status, treatment preferences and comments andchanges to history as noted by the patient.

An on-line help feature can also be provided to facilitate serviceprovider use of the invention. The on-line help is a file on the serviceprovider's computer which can walk a caregiver through the process ofaccessing and loading information from any source, whether the ICCrecord only or steps involved in accessing the central host(s)subscriber/medical history database and performing the operations ofaccessing, downloading and using diagnostic codes.

These steps allow the health care service provider (see FIG. 3, element58) to quickly access a list of current problems, a trail of clinicallogic, the service recipient's health status, and the most recentinformation about various treatment options for the service recipient'scondition. The health care provider's rationale for clinical decisionscan also be accessed. In the preferred embodiment of the invention,routine service recipient care, organizational operations and decisionmaking processes are supported. In addition, since all consultationrecords are stored in the subscriber's medical history database, healthcare service providers can avoid requesting redundant medical tests fora service recipient.

In the preferred embodiment of the invention, the service provider'scomputer software supports a GUI that simplifies access and extends useof the information, permitting users to analyze, transfer, process andcompare information using other standard market software packages whichextend the system capabilities. Such simplified access also allowsintegration of customized local features, such as inclusion of text,tables, graphics, video, animation, and audio display.

The GUI is configurable to display information related to the healthcare service provider's focus. Thus, the GUI can be configured, forexample, to display information related to a current query or problem,organized by date, or organized by symptom. In alternative embodimentsof the invention, the GUI is configurable to display any informationstored in the subscriber/medical history database, which can be linkedby the standard system key identifiers to customized capabilities andfeatures maintained on local storage media or accessed via links toremote network addresses. As an example, a teaching hospital can havevideo display modules, identified by the standard system diagnosticcodes, which allow the service provider to select video diagnostic helpthrough the standard GUI, allowing the service provider to view trainingsteps in a recommended procedure.

The service provider can access the service recipient's health carehistory and information regarding any potential diagnosis. Thisinformation can be printed, or displayed on a computer display, or onthe display of a personal portable device. The time spent by the serviceprovider in preparing written records and histories can therefore besignificantly reduced.

Using the Update Medical History processes 142, a practitioner cancommunicate with health care providers, insurers, sponsors and servicerecipients, provide preventative advice and health maintenanceinformation for service recipient self-care, review service recipientpreferences and generate care plans, document services provided, assessand manage the risks of various possible treatments for a servicerecipient, authorize treatments and care options, authorize referralswithin a Service recipient's care network, or send messages to otherservice providers or organizations.

Using software operable on the service provider's computer in anoff-line mode, the service provider uses the service recipient's recordfrom the subscriber/medical history database 122 and the selecteddiagnostic codes which were accessed and downloaded to the serviceprovider's computer through the Patient History process described above.

Software operable on the service provider's computer provides customizedscreen record formatting. The service provider uses an update recordprocess to update the service recipient record with information obtainedduring a current appointment. Test results can be loaded into theservice recipient's record manually or through an electronic automatedinterface into the record, such as through electronic monitoringdevices, and other patient care equipment for adding data, images orother formats into the record. Because the service recipient's healthcare history information is readily updated using the electronicnetwork, a health care service provider can monitor subsequent servicerecipient care and the reporting of any adverse reactions.

The preferred embodiment of the invention provides links toadministrative, bibliographic, clinical knowledge and researchdatabases. If the service provider wishes to review on-line diagnosticinformation through the AI Medications/Procedures functions, the serviceprovider uses software operable on the provider's computer to select adiagnostic assistance feature which prompts the provider to selectsymptom codes (as included during patient examination), test results,etc. and to define procedure and medication limitations by notingcategory codes for allergies, current conditions and medications, orother limiting factors.

General database searches can also be constructed. These queries can beconstructed on-line or off-line from the central host(s). To connect tothe central host(s), the service provider uses software operable on theprovider's computer to access the central host(s), provides requiredsecurity responses, and transmits the search record to the centralhost(s). The central host processes the search and returns the resultrecords to the service provider, or in the case of video informationlinks, allows the service provider to view the search results throughthe communication connection.

The service provider can also use the communication facilities toconstruct a message to referred specialists for later response. Usingsoftware operable on the provider's computer, the service provider canselect procedural and/or medication codes to run a conflict searchagainst the service recipient record and, if no conflict is noted, pastethe selected treatment/procedure/medication/referral codes into theservice recipient record and prepare a request for authorization throughthe central host(s). If codes resulting in conflicts are used by theservice provider anyway, that information is appended to the servicerecipient record.

In addition, a service provider can construct a research request to theResearch Request database 162 on the central host(s). This facility canbe used to perform outcomes research on specific diagnostic codes or toidentify a care network containing other individuals with the sameprognosis as one of their service recipients. Using software operable onthe service provider's computer, screen options in the Update MedicalHistory component allow the service provider to construct a researchrequest using a service recipient record, or using individual diagnosticor treatment codes. This record is then transmitted to the centralhost(s) and the result of the search is returned to the service providerat a later on-line session.

The service provider uses software operable on their computer toconstruct an authorization for services and/or authorization forreferral. This date and time stamped record contains service recipientidentification and plan information, service provider identification,and procedure and/or medication codes and referral codes, which aretransmitted to the central host(s). The central host(s) tags the requestwith a unique authorization request number, verifies the servicerecipient plan information from the subscriber/medical history database,verifies status of the service provider and reads plan coverageinformation for the affected plan(s) from the Plan/Benefit database,calculates payment amounts for all affected parties if multiple payersare involved, creates an authorization record in the provider servicehistory/payment and subscriber/medical history databases, and returnsthe numbered service authorization record with approval codes andpayment amount notification to the service provider.

If a referral has been requested, the central host(s) identifies serviceproviders available through the service recipient's plan(s) byidentifying providers from the service provider database, returning alisting of names with address, phone number, affiliations and otherinformation as an attachment to the authorization. If a plan availableto a service recipient covers disability, worker's compensation or othersupport benefits which apply for the prognosis, this information canalso be returned in the record, if requested by the service provider.

If a referral was requested, the service provider can select a serviceprovider from the on-screen returned list, send a message to theselected referral service provider which includes the service recipientrecord, the authorization message and a request for appointment or anyother information. This referral authorization information can also beprinted for action by the service recipient or a staff member at theservice provider's location and can cover prescriptions forpharmaceuticals and medications as well as procedures and services.

Negative results of conflict edits that were ignored by the serviceprovider is included on any printed output. If no referral is needed,the authorization is saved in the service provider's computer for latertransmittal to the central host(s) during the Service Payments andRecord keeping processes. When a request for authorization is declined,due to parameters of the plan, the central host(s) transmits an on-linedecline message to the medical insurer/benefit provider and the serviceprovider, which can initiate a manual review procedure to handleexceptions, appeals and questions.

When all health care history update activities have been completedand/or all service recipient payments have been made (defined in ServicePayments and Record keeping 148), the service provider can use softwareoperable on their computer to update the service recipient's record ontheir personal information device. In the preferred embodiment, theservice recipient's integrated circuit card is updated by swiping itthrough the service provider's card reader and downloading the mostrecent record information.

In addition, information from the service recipient record can be usedto print a variety of hard copy reports (as in the case of printedauthorizations or prescriptions, as defined above). Software operable onthe service provider's computer allows the provider to select a printoption which then brings up a list of standardized (and customized)reporting formats, including but not limited to: service authorizations,prescriptions, full health care history record of the service recipient,letters, discharge summaries, evaluation queries, insurance forms,school and camp certificates, trend reports and graphs.

When the service provider uses the on-line diagnostic functions in AIMedications/Procedures, the central host(s) uses the search record sentby the service provider (described above) to construct a query of theMedications/Procedures database. This diagnostic information can be usedto assist the health care service provider in determining whether aprocedure or medication is, for example, effective and safe,cost-effective, and whether it produces desired outcomes.

A summary of reference information is returned to the service provider'scomputer, where the service provider selects an item and, if it is areference only, can choose to see the entire record, including images,video or other forms of multimedia. The service provider can selectdiagnostic, treatment, procedure or medication codes and electronicallyadd them to the service recipient's record and can run an alert check onthe updated service recipient record to identify any elements causing acare or treatment conflict. Alert checks are performed by the centralhost(s) by running a central host program for a treatment, procedure ormedication code against the flag edits for those care components.

Conflicts are identified within the treatment/procedure/medicationrecord by their standard code. These include other medications andprocedures currently prescribed to research the effects, dosages, andside effects of medications prior to issuing a prescription, and alsocovers allergy or personal information such as age and condition factorswhich can result in complications or treatment incompatibilities. Theresult of this process is returned to the service provider's computerand displayed visually on the screen and can in addition provide anaudio signal, allowing the service provider to select a different careoption.

If the alerted care component is kept in the treatment plan for theservice recipient, an alert message is included in the servicerecipient's record and on any printed record of the service recipient'scare plan, including prescriptions. These processes are performedon-line to the central host(s) with software operable on the serviceprovider's computer used to search, review results, check for carecomponent conflicts, communicate to others in the health care process,and add search results to the service recipient's record. Information inthe AI Procedures/Medication database can only be updated by licensedauthoritative organizations with secured access to the central host(s)as defined in Update Medications/Procedures, described below.

The invention permits a practitioner to communicate electronically withother practitioners, either practicing with the same health care serviceprovider or with other Providers using the invention. The health careservice provider can use the invention to review service recipient planparameters, including identification of procedures, pharmaceuticals,referral providers and other care plan components covered by the plan,payment/reimbursement ceilings and out-of-network services coverageparameters. The provider to is thereby assisted in generating an optimalcare plan that maximizes the service recipient's coverage.

The preferred embodiment of the invention includes a feature within thecentral host(s) database processing steps for checking data integrity toensure that data are not lost or unknowingly corrupted. During theprocesses whereby new records are added to a database (such as thesubscriber/medical history database), data elements are run through editroutines defined within the central data dictionary to ensure that datavalues are for correct standard diagnostic or procedural codes and thatvariable values are within correct ranges. If invalid entries aredetected, the central host(s) returns a data error message to theservice provider initiating the entry which defines the problem with theattempted entry and requests the service provider to review andre-submit the entry.

In this way full data integrity checking is incorporated in databaseupdate processing. Also, to ensure unauthorized updates are not made,all data owners have update capabilities limited by their securityaccess. For example, medical insurer/benefit providers are limited toupdate capabilities for their plans only within the total Plan/Benefitdatabase, the addition of subscribers to their plans in thesubscriber/medical history database and adding service providersaffiliated to their plans in the service provider database. Recordsother than their own, or fields within those databases which lie outsidetheir required functions cannot be updated under their securityparameters.

These security parameters are also identified within the central host(s)data dictionary. Security parameters such as these are defined for allsystem users through security management. Unauthorized attempts atinformation access are logged within the central host(s) Securitymanagement platform services. These audit trails are monitored bycentral host security administration and may be communicated toauthorized agencies as defined within the data dictionary securityparameters (as an example; breaches of security within the serviceprovider network may be reported to the Agency for Health Care Policyand Research or a delegated security organization).

In the preferred embodiment of the invention, the data dictionarycontains one or more acceptable values tables to standardize codes andprovide a uniform health care vocabulary. For each element defined inthe central data dictionary, valid entries (or acceptable values) aredefined and updated as additional categories or new ranges are approved.These values can be defined by authorized expert organizations, such asnational health management organizations (such as the Agency for HealthCare Policy and Research, the Food and Drug Administration, or otherorganizations to which these responsibilities have been delegated bylegislation or agreement) in determining standardized diagnostic codesand data ranges.

Processes by which this information is incorporated into the centralhost(s) is defined in Update Medications/Procedures and Update serviceprovider information described later in this document. Thesestandardized codes are what ensures data integrity throughout the datavalue chain as defined within this document and ensures its universalconsistency and therefore its value. Such standard codes are used tolink related information within the system, such as health careliterature and specialists.

Another process of this invention provides uploading of the newlyrevised time-stamped service recipient care records for updating thecentral information system and the service recipient's portableinformation device.

The Service Payments And Record keeping processes 148 of the inventionprovide documentation of services and automation of service payments,insurance claims submissions, and electronic fund transfers for servicepayments. Such documentation can include the preparation of periodicaccounting reports.

A record of non-reimbursed amounts may also be maintained. An automatedbilling can therefore be submitted for un-reimbursed services. Paymentrecords can be updated to reflect manually received payments andadjustments to records. The preferred embodiment of the inventionprovides electronic payment services between service providers andmedical insurer/benefit providers (as described from the MedicalInsurers' Service Payment Accounting functions earlier in this document.Electronic funds transfer payments are noted on matching records in theprovider service history/Payment database 114 and to the matching recordin the subscriber/medical history database.

Using the software operable on the service provider's computer, theservice provider uses software operable on their computer to access thecentral host(s) and perform security functions. An audit file ofpayments made to their provider ID during the last central host paymentprocessing file is downloaded. The service provider can then downloadfull records from the central host(s) under their provider ID from theprovider service history/Payment database.

In addition, all or selected subsets of records can be downloaded (suchas between selected dates, all records with unpaid balances, all recordswith recent payments or any combination of the above) for use inoff-line administrative processing. Electronic messages to the serviceprovider including communications, exceptions and other exchanges canalso be downloaded. The service provider can then disconnect from thecentral host(s) and can perform account administration functionsoff-line.

Authorizations for current services (the result of activities describedabove in Update Medical History) are appended to the downloaded recordsas they are created. During the day's activities, software operable onthe service provider's computer can be used to log payments made byservice recipient or other adjustments to service/payment records. Inaddition, if the service provider wishes to perform a manual billingprocess for unpaid services, the contents of this file can be used witha report feature on their computer to print invoices for unpaid balance.

As each provider service history/Payment record is updated it can beselected for later batched transmission to the central host.Transmission during the next on-line session is the default, howeverfuture record transmission dates can be chosen. Other software operableon the service provider's computer allows the user to select a record inwhich there are questions, exceptions or other process problemsassociated and construct a message to the appropriate party (such as themedical insurer/benefit provider, etc) or to request affiliation in anew plan, communication with other service providers or any other partywith access to the central host(s).

All communications and updated records are batched for transmissionduring the next on-line session (or the requested future dated session)with the central host(s). Software operable on the service provider'scomputer is used to access the central host(s) and perform securityprocedures. At that time, files bound for the service provider aretransferred from the central host(s) to the service provider's computerand files bound for the central host(s) are transmitted for central hostprocessing.

Medical research processes (see FIG. 3, element 60) support researchorganizations in such areas as product development, public health,utilization and quality review, regulatory and compliance review,education, and scientific and health care research. FIG. 8 is a flowdiagram of the medical research processes according to the preferredembodiment of the invention health care service providers and servicerecipients can also use the medical research processes to researchtreatment options and development support and information networks.

Data warehouse queries 160 are conducted using the standardizeddefinitions stored in the data dictionary. The frequency of a datasearch can be specified. Thus, automated periodic data downloadsubscriptions are available for long-term research projects. Changes mayalso be made to existing periodic data subscriptions. Using the softwareoperable on the medical researcher's computer, the medical researcheraccesses the central host(s), provides required security responses,accesses the Research Request database and downloads data dictionaryinformation for the central host databases (subscriber/medical history122, Plan/Benefit 102, service provider 104 and provider service history114) before disconnecting from the central host(s).

This information can be stored on the medical researcher's computer forfurther data selection, until such time as the information is no longercurrent (date of last update of the central data dictionary can bechecked for currency). The medical researcher can then use softwareoperable on their computer to construct their data query by selectingdesired data fields from the data dictionary of the central databases,ensuring from the rules in the data dictionary that appropriateauthority is available for access to the data (security rules limitaccess to certain fields, and requests for non-authorized data will bereturned from central host processing with a security restrictionmessage).

Data queries can be specified as one-time only or can be requested on anongoing, time-specific basis for continuing research efforts. When alldata queries have been completed, software within the medical researchercomputer accesses the central host(s) and performs the securityprocedure, then the request file is downloaded to the central host(s)and questions regarding desired implementation dates are answered by themedical researcher.

The change queue request is verified, the medical researcher candisconnect from the central host(s) and the central host(s) performs thedata search requests on the appropriate databases and communicates theresulting data extract files (or error messages if the query was notconstructed correctly or encountered security restrictions if requestswere made for unauthorized information) to the medical researcher fortheir access and manipulation using software operable on their computer,as needed.

The reporting format for data received in response to such query mayalso be defined. For example, individual histories can be selectedaccording to such criteria as prognosis, treatment codes, severity ofillness, treating organization or individual care unit, and for episodesof care. For confidentiality purposes, data can be stripped ofidentifying information and searched, for example, by location ordiagnostic codes. Information returned from the search can then beaccessed by standard data analysis tools or by customized modelsallowing the researcher to perform the modeling or reporting methodsneeded to support their project.

A user's query is transmitted to the Research Request database 162 forprocessing through the Communication Link With Statistical Reportingprocesses 166. The Research Request database uses the query parametersto link keys within to the appropriate system databases, and theresponsive information is returned, for example, electronically (or inprint image format, if desired) to the user. This electronic informationcan then be used for statistical and graphical analysis, for example, byloading into standard statistical software packages.

The health care data can be provided for research, education andmonitoring purposes. Such data can be used by health professionalschools and programs, accreditation organizations, licensing agencies,disease registries, government agencies, lawyers, health careresearchers, clinical investigators, technology developers andmanufacturers, health data organizations, health sciences publications,research centers, medical peer review organizations, quality assuranceorganizations, risk management organizations, utilization review andutilization management organizations, and other users of health careinformation.

As the researcher is able to define the data elements and parameters oftheir search, the researcher has significant flexibility in identifyingthe desired research database, which is selected from the full systemdatabases. Therefore, the data elements and selected values to beextracted can exhibit wide variety and customization to the actual needsof the organization performing the search.

Because of this, the invention can also provides data access forregulatory purposes. Such information includes evidence for litigation,assessment of compliance with laws or standards of care, accreditationof care providers and organizations, and comparisons of health careorganizations, professionals and procedures.

For example, if a regulatory agency wished to identify service providersengaged in fraudulent procedures, a search could be constructed definingtarget codes defining episodes of care from the provider servicehistory/Payment database and, linked to the service provider database,would add identification fields to the targeted records. If insuranceplan information were also under investigation and long term analysis ofthe service recipient care were being analyzed, the search could beextended to select records with linking fields from the Plan/Benefitdatabase and the subscriber/medical history database.

Using the same query selection process this invention permits users toaccess information for research purposes. Such research purposes includenew product development, clinical research, technology assessment,service recipient outcomes, identification of at risk populations,service recipient care effectiveness and treatment cost-effectiveness,and the development of registries and databases.

The invention can also provide data for analysis of past clinicalexperience within a provider setting. Search parameters of thesubscriber/medical history database in these cases would primarily focuson standard diagnostic codes and could return entire case histories forthe Researcher's use in modeling and analysis. When analysis ofcost-effectiveness are needed, the search parameters would also includeinformation within the provider service history/Payment database. Allrequested fields for all records would be returned in a relationaldatabase format for use by standard relational database modeling systemsand applications.

Constructing an appropriate search from all available data dictionaryfields, the invention can provide information to assist in policydevelopment, such as resource allocation, workload assessment, riskassessment, strategic planning and public health monitoring, trendanalysis, forecast development and cost management. The invention canalso provide information for use in the health care industry, such asresearch and development, marketing strategy planning, case mixdocumentation, quality assurance planning and implementation, and costmanagement policy planning and implementation.

Information may be supplied for institutional uses, such as costreporting, budgetary, productivity and quality assurance purposes, forhospital accreditation, risk management and market placement analysis,personnel recruitment, equipment acquisition, and facilitiesdevelopment.

Standardized pre-selected information processes 164 support integrationof new subscription search data with original baseline data for ongoingresearch. Subscription query criteria or search frequency can be updatedand electronically transmitted to the system. For example, adversereactions to a medication or occurrences of a disease can beautomatically tracked over a period of time.

Features of the software operable on the Medical Researcher's computersupport simplified processes for appending data returned from ongoingperiodic searches of the system databases onto a previously collectedrelational database located on the medical researcher's computer. Thesoftware will provide the data format of the newly retrieved databaseand will request the target local database. When the researcheridentifies the target database, the software will provide the dataformat of the target database and note any discrepancies. If there areno format discrepancies, the software will perform a record appendprocess. If there are format discrepancies, the software help screenswill be available for the researcher to resolve the discrepancies priorto another attempt to append the new data.

The invention also supports comparisons of local, state, national andinternational health data such as prognosis, treatment options, and costof care. This information can then be used to promote regional, nationaland international health objectives. Such information includes data onmortality, morbidity and disability, injuries, personal, environmentaland occupational risk factors, preventative and treatment services,costs, and actuarial analyses. As in the descriptions of the dataselection process for other disciplines, field values within thedatabases provide the search base and are performed in the same manneras described above. In this way, service recipient location identifiers,standardized job codes, diagnostic codes for injuries or any other keyselection criteria included in the system databases and defined in thedata dictionary can be used to provide the researcher with theirpopulation base for their chosen research purpose.

Service support processes support internal maintenance and productbilling functions. FIG. 9 is a flow diagram of the service support (seeFIG. 3, element 62) processes, according to the preferred embodiment ofthe invention. The diagram shows the underlying platform of central hostshared processing applications, services and utilities which enablefunctional use of the central host(s) databases. This shared platform ofservices includes: database update processing 178,applications/management 180, database management 182, data dictionary184, security management 186, account parameters 188, system activityfile 190, communication/file transfer 192 and a central electronicoutput/archive 194.

System/service management processes 170 provide system control overprocessing functionality and service management support for systemcustomers. The shared platform of services are used by all central hostcomputing functions, perform automated processing, update and systemsmanagement support functions and are monitored by system maintenancepersonnel who have override capabilities via central maintenance controlpanels on their computers.

Among the central host system management functions are full data backupand restore capabilities, for example, ensuring that data stored in themedications/procedures database 146 can be completely restored in theevent of a system failure. In this case, a coded instruction set withinapplications/management 180 would be initiated at a pre-determined timeto use a backup utility program under it's central control to perform abackup operation to the electronic output/archive 194. If a databasefailure were experienced, system maintenance personnel can use theircentral maintenance control panels on their computers to initiate arestore process on the medications/procedures database.

In the preferred embodiment of the invention, files containing theadjusted values of social security, annuity, retirement account andbenefit information are automatically updated. Again, software residingon the local computers of system maintenance personnel can be used toschedule files to be electronically appended to records in the targetdatabase. In this case, processing control would be done throughdatabase update processing 178 platform functions which would invokedatabase management 182 services and data dictionary 184 updates ifchanges to the format of the targeted databases were needed.

Records can be stored on the system indefinitely, or for a specificperiod of time as defined for each field within each database viaretention parameters within the data dictionary. These data dictionaryparameters can only be changed through the system maintenanceinstruction set. Such records can also be archived or purged, ifdesired, through the data management services which would transmit anarchive copy of the database to the electronic output/archive or wouldinvoke purge processing functions within the same shared platformservice instruction set.

Security parameters defining access groups and identifying dataavailability for these groups for each data field (or value range withineach field) in each system database are also under secure centralhost(s) control within the security management 186 platform services.System security staff access computer screens allowing them to definesecurity instruction sets within the security management platformservices. These instruction sets provide security access and capabilitylevels for all system users in all system processing activities.

Customer Service features, provides the central setting of accountparameters 188 in the central platform services to add new systemaccounts such as medical Insurer/benefit providers, medical researchersand service providers for inclusion in the system, to define billingparties for the system services, any tiered pricing parameters andparent/child account relationships for roll-up billing. In addition,central service control functions are provided via screen entriesappended to central host(s) databases. These operate as a central filesystem override by adding an update record on the target central host(s)database.

This update record is appended to the original record and both theoriginal and the update are maintained to support full auditavailability for all system records. In addition, a problem trackingsystem accessible to all system users can also be implemented under theapplications/management 180 set of shared platform services. Thepreferred embodiment of the invention provides full arbitration anddispute resolution support to all system users by allowing customerservice central personnel to use software operable on their computers toscan documents into a database record or select electronic messages,embed them in an electronic folder via the communications/file transfer192 shared platform services and transmit them to any party with systemaccess.

In support of these dispute resolution capabilities, customer servicecentral personnel have authorized system security access to update anyfile through appending an attached record to the record under dispute,as described above. In this way a full history on a record is maintainedwithin the central host(s) databases, however a customer service centralrecord can override an automated activity. An example would be a paymentdispute, where a service payment was made but has been questioned. As aresult of an investigation supporting payment reversal, the customerservice central staff member could append a funds reversal record on theprovider service history/payment database which would be calculatedduring the central host(s) service payment accounting cycle as anegative amount during the payment processing cycle and deducted fromthe value of a future funds transmission between the parties.

Additionally, questions from any system customer regarding systembilling can be supported through an on-line billing history archivewithin the electronic output/archive 194 which allows a customer servicecentral staff member to select the applicable subset of an electronicarchived report (in central host administered central storage) createdduring central host processing cycles and, using software operable ontheir computer, to embed the contents into an electronic message to therequester, whether that requester is a service provider, a researcher, amedical insurer/benefit provider, a health plan sponsor or a servicerecipient for transmission by the central host communication feature setwithin communications/file transfer 192 shared platform services.

The electronic communication features within the messaging/file transfershared platform services of the invention is available to all centralsystem maintenance, security and customer service staff members toexpedite addressing inquiries, problem resolution, setting tiered rates,and making adjustments to rates or for any other customer or systemrelated reason.

Customer billing processes 172 provide integrated service billing forclient organizations, such as insurers, sponsors, service providers andresearch users. As defined in the customer service support under theSystem/Service Management functions described above, organizations candefine the appropriate billing roll-up in accordance with theirindividual cost accounting process. These parameters are used during thecustomer billing processing cycle. During the on-going use by the systemusers of the system features, as functions are performed counters forthe function per account are incremented in the system activity file 190shared platform services.

On billing processing dates (which can be defined in the Accountparameter 188 shared platform facility, the central billing applicationreads the system activity file and the account parameter records for thebilling period and produces an electronic invoice of costs per servicecategories and total service charges per billing entity. Theseelectronic invoices are transmitted electronically to the customerthrough the communication/file transfer 192 shared platform service witha copy transmitted to the electronic output/archive 194. If desired, theelectronic transmission can accompany an electronic funds transfer fromthe customer to the system central processing facility, also performedthrough the Communication/file transfer platform services.

The Update Medications/Procedures 174 processes of the invention provideentry of and changes to standardized codes for all prognoses,treatments, medications and treatments. Designated organizations andagencies can securely add values to field categories within the datadictionary shared platform service and access the medications/proceduredatabase 146 to update medications and procedures information. Theauthorized agencies can review on-line, download, or print any of theinformation stored in the medications/procedure database.

Using the software operable on the agency's computer, the user accessesthe central host(s), provides required security responses and accessesand downloads the current data dictionary and records within theMedications/procedures database. New information for any of theappropriate sources can be added, deleted or changed manually or througha file append feature within their computer software. Such updates caninclude the identification via new category codes, descriptions andcodes identifying warning conditions or incompatibilities, for newdiagnoses, procedures, pharmaceuticals, etc. and can add informationalrecords supporting any of these.

Changes are accompanied by active dates, defaulting to current dates,which allow advance notification on developing procedures or forupcoming FDA approval. Batched update features and copy capabilities forcurrent record information is available to simplify changes to records.When all changes have been completed, edited for format correctness andan on-line audit approved, software within the agency's computeraccesses the central host(s) and performs the security procedure, thenthe updated file is downloaded to the central host(s) and questionsregarding implementation dates/times, whether and to whom automatednotifications are to be generated, and whether other approvalcommunications are needed prior to submitting the change to the datadictionary or the medications/procedures database. The change queuerequest is verified, the agency can disconnect from the central host(s)and the central host(s) performs the requested operations.

The update service provider information processes 176 are available topermit authorized organizations to create, update and delete informationstored in the service provider database 104. This information includesrecords for licensed practitioners, records for licensed organizations,and organizational ownership information. Service provider records canalso be updated to reflect continuing education classes attended by, anddisciplinary action taken against a service provider.

Using the software operable on the agency's computer, the user accessesthe central host(s), provides required security responses and accessesand downloads the appropriate current records within the serviceprovider database. New licensing, continuing education, disciplinaryaction, organizational ownership or other information for those recordsto which the agency has security control can be added, deleted orchanged manually or through a file append feature within their computersoftware.

Changes are accompanied by active dates, defaulting to current dates,which allow advance notification on organizational ownership petitions,for example. Batched update features and copy capabilities for currentrecord information is available to simplify changes to records. When allchanges have been completed, edited for format correctness and anon-line audit approved, software within the agency's computer accessesthe central host(s) and performs the security procedure, then theupdated file is downloaded to the central host(s) and questionsregarding implementation dates/times, whether and to whom automatednotifications are to be generated, and whether other approvalcommunications are needed prior to submitting the change to the serviceprovider database. The change queue request is verified, the agency candisconnect from the central host(s) and the central host(s) performs therequested operations.

Although the invention is described herein with reference to thepreferred embodiment, one skilled in the art will readily appreciatethat other applications may be substituted for those set forth hereinwithout departing from the spirit and scope of the present invention.

For example, the functional areas of the invention are extensible toallow secure access to social security, annuity and retirement accountand benefit information. Individual service recipients are therebyprovided a unified view of their benefit and payment status. Thisinformation is accessed using the individual information device.

One skilled in the art will readily be able to construct the hardwareand software required for the invention using well-known programmingtechniques and equipment. Accordingly, the invention should only belimited by the claims included below.

1. An integrated health care system, comprising: at least one centralhost computer system for maintaining, consolidating, and distributinginformation generated by any component of said system; at least one of aremote, single provider, or networked provider terminal in communicationwith said central host computer; at least one individual informationdevice for accessing said system; and a common data dictionary; whereinsaid service recipient's health care data records are stored on any ofsaid central host computer, said terminal, or said individualinformation device; wherein said central host computer, said terminal,and said portable individual information device are electronicallylinked as a network, to permit information distribution to variouslocations on said network, and wherein said common data dictionaryfacilitates said information distribution among said various locationsby standardizing system database elements; and wherein open standardsare used for hardware, software, and firmware components of said system.2. The system of claim 1, wherein said portable individual informationdevice stores any of an individual service recipient's insuranceinformation, emergency records, and health care history.
 3. The systemof claim 1, wherein said remote, single provider, or networked providerterminal comprises any of: a medical insurer module; a health plansponsor module; a health care service provider module; a health careresearch module; and a service support module.
 4. The system of claim 3,wherein said medical insurer module supports any of plan definition,open enrollment marketing features, automated authorization of benefits,automated referrals, and service payment accounting.
 5. The system ofclaim 3, wherein said health plan sponsor module supports any of openenrollment processes, maintaining benefit plan information, andcoordinating distribution and deactivation of individual informationdevices.
 6. The system of claim 3, wherein said health care serviceprovider module supports any of maintaining service recipient records,diagnostic and treatment support, service payment management, accountingservices, and maintaining service provider records, including licensinginformation, staffing affiliations, organizational ownershipinformation, tax identification information, curriculum vitae oflicensed practitioners, and well as information regarding disciplinaryactions.
 7. The system of claim 3, wherein said health care researchmodule supports the collection of data on said system for research andanalysis of health care issues.
 8. The system of claim 3, wherein saidservice support module supports any of service parameter maintenance,product support, customer requests, and system maintenance.
 9. Thesystem of claim 1, further comprising an integrated statistical analysissoftware package linked to said system for providing statisticalanalysis of said information stored in said system.
 10. The system ofclaim 1, further comprising a billing module for calculating billinginformation for a service provided to said service recipient.
 11. Thesystem of claim 1, further comprising an insurance benefits module forcalculating available insurance benefits for a service provided to saidservice recipient.
 12. The system of claim 1, further comprising apayment module for electronically transferring funds to pay a bill forservices provided to said service recipient.
 13. The system of claim 1,further comprising an authorization module for authorizing servicerecipient treatment.
 14. The system of claim 1, wherein said centralizedhost computer system is one of a computer, or a network of linkedcomputers having at least one central server.
 15. The system of claim 1,wherein said individual information device is any of an integratedcircuit card, a magnetic storage card, or a portable integrated circuitor microchip-based device.
 16. The system of claim 15, furthercomprising a card reader, linked to said remote, single provider, ornetworked provider terminal, for accessing information stored on saidindividual information device, and for transmitting information amongsaid individual information device and any of said components of saidsystem.
 17. The system of claim 1, wherein said remote, single provider,or networked provider terminal is one of a portable computer, personalinformation device, personal computer, or server computer.
 18. Thesystem of claim 17, wherein said remote, single provider, or networkedprovider terminal is operable to communicate with said entire system orany portion of said system, or is operable independently from saidsystem.
 19. The system of claim 1, further comprising a messaging modulefor providing messaging services to a component of said system.
 20. Thesystem of claim 1, wherein said system is implemented using any of theInternet, or a local area network.
 21. The system of claim 1, whereinsaid system provides access to any of Social Security, annuity,retirement account, and benefit information.
 22. The system of claim 1,wherein said common data dictionary comprises: field definitions; andacceptable codes or values organized in acceptable values tables toprovide a uniform healthcare vocabulary; wherein said codes ensure dataintegrity throughout a data value chain and ensure the data's universalconsistency.
 23. The system of claim 22, said data dictionary furthercomprising: edit rules; format rules; identification of a field's dataowner, wherein the owner has ultimate authority for issuing updates andrevisions to the field; and references to diagnostic, procedural,pharmaceutical and personal information codes for use in processingchanges to databases and in construction of research requests toidentify potential incompatibilities and problems; wherein a databaseaccesses data dictionary codes when responding to a query so thatinformation retrieved in response to a query is limited to those casescontaining no potential incompatibilities or problems.
 24. An integratedhealth care system, implemented using any of the Internet or a localarea network, the system comprising: at least one central host computersystem for maintaining, consolidating, and distributing informationgenerated by any component of said system; at least one of a remote,single provider, or networked provider terminal in communication withsaid central host computer; a portable terminal in communication withsaid central host computer, wherein said portable terminal is operableto communicate with said entire system or any portion of said system, oris operable independently from said system; at least one portableintegrated circuit card for accessing said system, wherein said portableindividual information device stores any of an individual servicerecipient's insurance information, emergency records, and health carehistory; a card reader, linked to said remote, single provider, ornetworked provider terminal, for accessing information stored on saidindividual information device, and for transmitting information amongsaid individual information device and any of said components of saidsystem; a messaging module for providing messaging services to acomponent of said system; and a common data dictionary; wherein saidservice recipient's health care data records are stored on any of saidcentral host computer, said terminal, or said portable individualinformation device; wherein said central host computer, said terminal,and said portable individual information device are electronicallylinked as a network, to permit information distribution to variouslocations on said network, and wherein said common data dictionaryfacilitates said information distribution among said various locationsby standardizing system database elements; wherein open standards areused for hardware, software, and firmware components of said system. 25.The system of claim 24, wherein said remote, single provider, ornetworked provider terminal comprises any of: a medical insurer modulefor supporting any of plan definition, open enrollment marketingfeatures, automated authorization of benefits, automated referrals, andservice payment accounting; a health plan sponsor module, said healthplan sponsor module supporting any of open enrollment processes,maintaining benefit plan information, and coordinating distribution anddeactivation of individual information devices; a health care serviceprovider module, said health care service provider module supports anyof maintaining service recipient records, diagnostic and treatmentsupport, service payment management, accounting services, andmaintaining service provider records, including licensing information,staffing affiliations, organizational ownership information, taxidentification information, curriculum vitae of licensed practitioners,and well as information regarding disciplinary actions; a health careresearch module, said health care research module supporting thecollection of data on said system for research and analysis of healthcare issues; and a service support module, said service support modulesupporting any of service parameter maintenance, product support,customer requests, and system maintenance.
 26. The system of claim 24,further comprising an integrated statistical analysis software packagelinked to said system for providing statistical analysis of saidinformation stored in said system.
 27. The system of claim 24, furthercomprising a billing module for calculating billing information for aservice provided to said service recipient.
 28. The system of claim 24,further comprising an insurance benefits module for calculatingavailable insurance benefits for a service provided to said servicerecipient.
 29. The system of claim 24, further comprising a paymentmodule for electronically transferring funds to pay a bill for servicesprovided to said service recipient.
 30. The system of claim 24, furthercomprising an authorization module for authorizing service recipienttreatment.
 31. The system of claim 24, wherein said centralized hostcomputer system is one of a computer, or a network of linked computershaving at least one central server.
 32. The system of claim 24, whereinsaid system provides access to any of Social Security, annuity,retirement account, and benefit information.
 33. The system of claim 24,wherein said common data dictionary comprises: field definitions; andacceptable codes or values organized in acceptable values tables toprovide a uniform healthcare vocabulary; wherein said codes ensure dataintegrity throughout a data value chain and ensure the data's universalconsistency.
 34. The system of claim 33, wherein said data dictionaryfurther comprises: edit rules; format rules; identification of a field'sdata owner, wherein the owner has ultimate authority for issuing updatesand revisions to the field; and references to diagnostic, procedural,pharmaceutical and personal information codes for use in processingchanges to databases and in construction of research requests toidentify potential incompatibilities and problems; wherein a databaseaccesses data dictionary codes when responding to a query so thatinformation retrieved in response to a query is limited to those casescontaining no potential incompatibilities or problems.
 35. A method forconsolidating information in an integrated health care systemimplemented using any of the Internet or a local area network, themethod comprising the steps of: maintaining, consolidating, anddistributing information generated by any component of said system withat least one central host computer system for; providing at least one ofa remote, single provider, or networked provider terminal incommunication with said central host computer; providing a common datadictionary; providing a portable terminal in communication with saidcentral host computer, wherein said portable terminal is operable tocommunicate with said entire system or any portion of said system, or isoperable independently from said system; providing at least one portableintegrated circuit card for accessing said system, wherein said portableindividual information device stores any of an individual servicerecipient's insurance information, emergency records, and health carehistory; linking a card reader to said remote, single provider, ornetworked provider terminal, for accessing information stored on saidindividual information device, and for transmitting information amongsaid individual information device and any of said components of saidsystem; providing messaging services to a component of said system;wherein said service recipient's health care data records are stored onany of said central host computer, said terminal, or said portableindividual information device; wherein said central host computer, saidterminal, and said portable individual information device areelectronically linked as a network, to permit information distributionto various locations on said network, and wherein said common datadictionary facilitates said information distribution among said variouslocations by standardizing system database elements; wherein openstandards are used for hardware, software, and firmware components ofsaid system.
 36. The method of claim 35, further comprising the step ofproviding access to any of Social Security, annuity, retirement account,and benefit information.
 37. The method of claim 37, wherein said commondata dictionary comprises: field definitions; and acceptable codes orvalues organized in acceptable values tables to provide a uniformhealthcare vocabulary; wherein said codes ensure data integritythroughout a data value chain and ensure the data's universalconsistency.
 38. The method of claim 37, wherein said data dictionaryfurther comprises: edit rules; format rules; identification of a field'sdata owner, wherein the owner has ultimate authority for issuing updatesand revisions to the field; and references to diagnostic, procedural,pharmaceutical and personal information codes for use in processingchanges to databases and in construction of research requests toidentify potential incompatibilities and problems; wherein a databaseaccesses data dictionary codes when responding to a query so thatinformation retrieved in response to a query is limited to those casescontaining no potential incompatibilities or problems.